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Background: Emergency medical services (EMS) are a critical but often overlooked component of essential public health care delivery in low-and middle-income countries (LMICs). Few countries in Africa have established EMS and there is scant literature to provide guidance for EMS growth. Objective: This study aimed to characterize EMS utilization in Harare, Zimbabwe in order to guide system strengthening efforts. Methods: We performed a retrospective chart review of patient care reports (PCR) generated by the City of Harare ambulance system for patients transported and/or treated in the prehospital setting over a 14-month period (February 2018 – March 2019). Findings: A total of 875 PCRs were reviewed representing approximately 8% of the calls to EMS. The majority of patients were age 15 to 49 (76%) and 61% were female patients. In general, trauma and pregnancy were the most common chief complaints, comprising 56% of all transports. More than half (51%) of transports were for inter-facility transfers (IFTs) and 52% of these IFTs were maternity-related. Transports for trauma were mostly for male patients (63%), and 75% of the trauma patients were age 15–49. EMTs assessed and documented pulse and blood pressure for 72% of patients. Conclusion: In this study, EMS cared primarily for obstetric and trauma emergencies, which mirrors the leading causes of premature death in LMICs. The predominance of requests for maternity-related IFTs emphasizes the role for EMS as an integral player in peripartum maternal health care. Targeted public health efforts and chief complaint-specific training for EMTs in these priority areas could improve quality of care and patient outcomes. Moreover, a focus on strengthening prehospital data collection and research is critical to advancing EMS development in Zimbabwe and the region through quality improvement and epidemiologic surveillance.
The City of Harare Ambulance (COHA) system is the oldest and longest running EMS system in Zimbabwe, having been initiated in 1984. This ambulance service is locally run under city authority and budget. It is the only government-funded EMS system in Harare and is available free of charge to all 2.1 million residents [15]. The EMS landscape in Harare also has numerous private pay-for-service ambulance services whose patients are those that have access to insurance or have the financial ability to pay for the service. However, over 75% of all Harare residents lack health insurance, with the prevalence of uninsured highest among people in the bottom 3 wealth quintiles (>98%) [16]. COHA operates advanced life support-capable vehicles staffed with trained providers and hosts the only public training center in Harare for EMS providers. COHA trains ambulance technicians, EMTs, and paramedics, who can either stay with COHA or go on to work in the private sector. Ambulance technicians have 4 weeks of basic life support training. EMT training is 12 weeks, including advanced life support training and five weeks of supervised practice. Paramedics are the most highly trained ambulance provider, with 30 weeks of advanced life support training. We conducted a retrospective review of patients who were transported and/or treated by COHA during the 14-month period from February 2018 to March 2019. For every EMS transport, ambulance providers record basic patient data and operation metrics on a standardized instrument, a patient care report (PCR). All PCRs are written in English on paper forms. Due to archiving methods, many PCRs have been damaged or lost over years. We reviewed all available PCRs from our study period. Ethical approval for this study was provided by the Stanford University Institutional Review Board (Palo Alto, California, USA; #50206), the City Council of Harare (Harare, Zimbabwe), and the Medical Research Council of Zimbabwe (Harare, Zimbabwe; #MRCZ/E/257). We created a standard electronic data collection instrument that mirrored COHA’s paper PCR forms. The paper PCR forms included several specific fields, including patient demographics, pickup location, incident type, patient vital signs, and patient condition on handover at the receiving facility. We created 5 additional fields to capture specific data the EMT may have noted in an area of the PCR with free text narrative: destination hospital; intervention by EMT; events during transport; impression by EMT; and a binary field indicating whether or not the EMT had performed a physical examination. For each of these, the lists were based on an initial review of the narratives and refined as new items were identified in the data. Two research assistants, with experience as COHA paramedics, were trained to extract study variables from the handwritten PCR forms. All data were securely collected and managed via REDCap (Stanford University) [17]. We conducted a descriptive analysis of patient demographics, chief complaints, and transport patterns, using descriptive statistics, providing frequencies and percentages as appropriate. Chief complaints were recorded as free text in the PCRs. Consequently, we chose to group chief complaints into 10 broad chief complaint categories using the categorization from Mould-Millman et al. [14] as a framework, which was chosen because of its regional relevance. Chief complaint categorization was completed by the lead author and then reviewed by the senior author to reach consensus. COHA also categorized transports by incident type. Incident type is an internally designated classification of the different call types that COHA receives. The dispatcher determines incident type based on COHA’s predetermined grouping: maternity, medical, road traffic accident (RTA) and other accident or assault. This is distinct from chief complaint in this study as chief complaints were determined by the patient and EMT. All data analysis was conducted in SAS Enterprise Guide for Windows, V.4.3 (SAS Institute, Cary, North Carolina, USA).
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